Thank you for choosing Merrifield Chiropractic Center, Inc. (MCC) for your wellness needs.  We look forward to serving you and helping you on your wellness journey.  These terms are provided by MCC Corp. and Concept Chiropractic and Regenerative Medicine (DBA)

TERMS CONCERNING HEALTH MAINTENANCE ORGANIZATIONS:

If you are a member of any Health Maintenance Organization (HMO), you agree that you have been informed that for the majority of services offered by MCC , neither MCC , nor any MCC  practitioners (when providing services on behalf of MCC ) are participating providers with your HMO and that if you obtain any MCC  services/products you will be billed at MCC ’s usual rates and you will be responsible for full payment of all MCC  charges.  You agree that if you obtain treatment from another health care provider who does participate in your HMO and that service is covered by your HMO, you would be entitled to reimbursement from your HMO as provided by the terms of your HMO plan.  YOU THEREFORE ACKNOWLEDGE AND AGREE THAT:

YOU WILL BE SOLELY RESPONSIBLE FOR ALL MCC CHARGES FOR SERVICES RENDERED BY MCC AND MCC PRACTITIONERS, AND

NEITHER MCC NOR ANY MCC PRACTITIONER WILL SEEK PAYMENT FROM YOUR HMO FOR ANY SERVICES THAT YOU RECEIVE AT MCC .

*One or more MCC practitioners may be out-of-network providers under certain HMOs and certain services performed by MCC , or on behalf of MCC , may be submitted to your HMO for reimbursement.  MCC will inform you at the time of service if any service you obtain will be submitted to your HMO for reimbursement.

Who We Are

MCC offers a variety of wellness services.  The MCC team includes physicians and other healthcare practitioners licensed in the state where services/products are provided.  MCC SERVICES/PRODUCTS ARE NOT A SUBSTITUTE FOR AND YOU SHOULD DISCUSS ANY WELLNESS PROGRAM WITH YOUR PRIMARY CARE PHYSICIAN.

Keeping Us Informed

MCC seeks to develop wellness through collaborative, open communications with our patients.  You agree to let MCC staff know of any disease or condition or any drug or supplement you are taking that may relate to the effectiveness of or interfere with any MCC services/products.

Understanding Your Payment Options

For certain services offered by MCC , we do not accept insurance or file claims with any insurance providers, including government providers such as Medicare and/or Medicaid.  (If you are a Medicare beneficiary or are Medicare eligible, please see the separate Medicare Private Contract Agreement.)  For services where we will not file claims with any insurance providers, as a convenience to you, we will provide you with summary information listing any MCC  services/products that you receive.  Unless applicable, MCC  practitioners are in-network with your insurance provider (or out-of-network for certain services where your insurance provider offers some coverage for such services*), you agree that: (a) we have not indicated that any MCC  services/products will be covered by any insurance or other benefits; and (b) we have not recommended that you submit any MCC  charges to any insurance or other provider for reimbursement.  For such services, you will be responsible for the full MCC  charges for all MCC  services/products that you receive, even if your insurance provider pays for similar services/products at a lower rate.  Payment in full must be made at the time of service/purchase. Certain services/products may require a non-refundable deposit.  If you provide a credit card, we may charge any credit card on file for services/products that you receive, including any patient responsibility portion where applicable MCC  practitioners are in-network with your insurance provider (or  out-of-network for certain services where your insurance provider offers some coverage for such services*).

*One or more MCC  practitioners may be out-of-network providers in connection with certain insurance providers and certain services performed by MCC , and any other party that performs services on behalf of MCC , may be submitted to your insurance provider for reimbursement.  MCC  will inform you at the time of service if any service you obtain will be submitted to your insurance provider and you authorize MCC  and any other party that performs services on behalf of MCC  to submit such charges to your insurance provider for reimbursement. For charges submitted to your insurance provider, you agree that you will be responsible for appropriate, allowed charges in the event that your insurer fails to provide reimbursement.

Our Cancellation Policy

We value our clients’ time and schedule appointments in an effort to best allocate MCC  staff resources so that clients receive prompt, thorough service.  We ask that you honor all MCC  appointments, and if for some reason you will not be able to do so, you must give us as much advance notice as possible.  You may cancel an appointment or reschedule it, so long as you do so by calling us at least 24 hours in advance of the scheduled time of a particular appointment.  If you do not provide at least 24 hours advance notice, you agree to pay a $100 fee for a missed medical appointment or a $75 missed appointment fee for a chiropractic appointment.  This fee will be charged to your credit card on file or collected at your next appointment (if no credit card is on file).

Prescription Choice

If a MCC  practitioner prescribes any medications for you, you agree that you have the right to obtain your prescription from any pharmacy of your choice.  A MCC  practitioner may offer to make a prescription available through one or more pharmacies for your convenience, but you may elect to have your prescription filled through any pharmacy that you select.  By accepting any prescription dispensed to you at a MCC  location, you agree that a pharmacy is not conveniently available.

How We Will Communicate With You

Use of Telephone:

If you provide us with a telephone number, we may contact you using that telephone number to discuss your MCC  wellness services, appointments, records, and purchases.

Use of Electronic Communication Methods:

Electronic communications include email messages, internet communication services (such as Skype™), or other electronic methods.  You agree that electronic communications are not secure and that there is the possibility that they may be accessed by other persons. You also agree that your employer may review any electronic communications transmitted through your employer’s computer system.  We may use email or other electronic communications to transmit routine information to you (such as appointment dates, newsletters, etc.).  We may also use email or other electronic communications to transmit information concerning your MCC  services and products, unless you tell us otherwise (as described below).  If you give us an email address or communicate with us using other electronic communications, you agree that: (a) electronic communications should not be used for emergency or other time-sensitive situations or where sensitive information will be transmitted (please contact us by telephone or visit a MCC  location); (b) we will use reasonable efforts to respond to electronic communications that you send (if you do not hear from us within 2 business days, please contact us by telephone or visit a MCC  location) and we will not be liable for any failure to respond or any intercepted electronic communications; (c) one or more MCC  staff members may need to access your electronic communications in order to help MCC  respond; and (d) MCC  may keep copies of electronic communications that you send in your client records.

Contact Authorization. 

By providing your mobile and/or home number (including any phone number that you later convert to a mobile phone number) to us through any request for services or otherwise, you consent to receive informational calls, text messages (including by auto dialers and/or with pre-recorded messages) by or on behalf of us regarding the processing of your request and for other transactional purposes.  You understand that your consent for non-marketing, informational calls and messages applies to each phone number that you voluntarily provide to us now or in the future.

If you do not wish MCC to use electronic communications to transmit information concerning your MCC  services/products, you can provide written notice to us at:  info@chiroregenmed.com or 2826 Old Lee Highway, Ste 350. Fairfax, Va 22031.